Mainstreaming cultural responsiveness: linking access, equity, quality and safety in Australian health services

1. Lidia Horvat Quality, Safety & Patient Experience Branch Policy & Strategy Unit lidia.horvat@health.vic.gov.au Mainstreaming cultural responsiveness: linking access, equity, quality and safety in Australian health services

2. Cultural and Linguistic Diversity in Australia • Top 10 Birthplace Groups • England, New Zealand, China, Italy, Vietnam • India, Scotland, Philippines, Greece, Germany • Top 10 Fastest Growing Birthplace Groups • Burundi, Liberia, Guinea, Sierra Leone, Rwanda, • Sudan, Democratic Republic of Congo, Oman

3. 68.7% followed more than 120 religions collectively Older Victorians 26% of people aged 65 and over were from NMESC 22% of them spoke LOTE at home One third were not proficient in English New and emerging communities and languages African Burmese General population Almost a quarter of Victoria’s population were born overseas in more than 230 countries 43.6% of Victorians were born overseas or had one parent born overseas 72.8% of those born overseas came from non-main English speaking countries (NMESC) 20.4% collectively spoke more than 200 languages other than English (LOTE) at home (over 1 million) Of these 185,000 speak English ‘not well’ or ‘not well at all’ Victoria, the most multicultural State

4. Health services in Victoria • Public system • 19 public health services in Victoria are incorporated public statutory authorities established under the Health Services Act 1988. (13 metropolitan, 6 regional) • 2 denominational • 57 rural public hospitals • 7 multi-purpose services • Community health centres • Private • Private health services

6. Metropolitan health services

7. Responding to Diversity in Victoria • Whole of Government reporting system • Suite of policies and programs in Department of Health For Health services: • Health Service Cultural Diversity Plans, and Cultural Diversity Committees since 2006 • Public reporting through health services’ annual Quality of care reports, on the six minimum reporting requirements • Minimum reporting requirements on quality and safety systems, processes and outcomes of the health service to consumers (patients), carers, family & friends, and the health service community

8. Quality, Safety and Patient Experience Branch • Review of cultural and linguistic diversity and cultural competence reporting requirements, minimum standards and benchmarks for Victorian health services, 2008-09 • Statewide consultation with health services Metropolitan , regional and rural Diverse range of health services staff High and low diverse population groups Focus groups with consumers, community members • 14 recommendations • Draft standards and measures tested at statewide forum, feedback mechanisms before finalisation

9. Key project findings • Absence of whole-of-organisation approach • Lack of appropriate standards for cultural diversity initiatives in Australian health system • Insufficient alignment between risk management, patient safety, quality improvement and cultural responsiveness • Need for clearly specified standards, measures and benchmarks to improve health services responsiveness to CALD issues

10. Drawing on the research and evidence base • Impact of culture and language on health disparities for diverse populations (Wilson-Stronks et. al: 2008, Betancourt et. al: 2003,) • Mounting evidence of disparities in patient safety: that people from diverse backgrounds receive poorer quality health care than mainstream patients, (Divi et. al, 2007, Suurmond et. al: 2010) • A ‘trajectory of accident opportunity’ and adverse events in their journey through the health system (Divi et. al, 2007). • Links between culture, language and patient safety outcomes (Johnstone & Kanitsaki: 2006)

11. Need for a viable strategy to…. • Concretise the links between access & equityandquality & safety, • Embed cultural responsiveness into core health service planning and implementation • Congruent with and explicit links with existing legislative and policy frameworks in Victoria, and national accreditation standards • Create standards to improve health care delivery and outcomes for culturally and linguistically diverse populations

12. Victorian legislative and policy context All of us Multicultural Victoria Act Victorian clinical governance policy framework 2009 Doing it with us not for us: Strategic direction: 2010-13 Victorian Patient Satisfaction Monitor

13. Victorian legislative and policy context • Australian Charter of Healthcare Rights • in Victoria • Victorian Charter of Human Rights • and Responsibilities Act 2006 • At a national level • The Australian Council for Healthcare • Standards • Australian Charter of Healthcare Rights

14. A new approach • Developed with health services • and the community • Launched in September 2009 • Congruent with legislative and • policy frameworks, demographics • and quality & safety • evidence

15. Cultural responsiveness • The term cultural responsiveness refers to health care services that are respectful of, and relevant to, the health beliefs, health practices, culture and linguistic needs of diverse consumer/patient populations and communities. • That is, communities whose members identify as having particular cultural or linguistic affiliations by virtue of their place of birth, ancestry or ethnic origin, religion, preferred language or language spoken at home. • Cultural responsiveness describes the capacityto respond to the healthcare issues of diverse communities. It thus requires knowledge and capacity at different levels of intervention: systemic, organisational, professional and individual.

16. The framework aims to facilitate • Awhole-of-agencyresponse and a systems approachto diverse • health needs by • Leading, governing and managing for cultural responsiveness • Communicating, collaborating and building community capacity across • the health service • Linking health service’s planning and implementation within a quality • and safety improvement framework • Building a more culturally responsive workforce and changes in • professional practice at all levels

17. Cultural responsiveness framework • Determines a minimum level of activity in four domains of quality and safety as per the Victorian clinical governance policy framework (2009): • Organisational effectiveness • Risk management • Consumer participation • Effective workforce

18. Six standards • A whole-of-organisation approach to cultural responsiveness is demonstrated 2. Leadership for cultural responsiveness is demonstrated by the health service 3. Accredited interpreters are provided to patients who require one

19. Six Standards • Inclusive practice in care planning is demonstrated, including but not limited to dietary, spiritual, family, attitudinal, and other cultural practices • 5. CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis • 6. Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness

20. Measures and sub-measures • Qualitative and quantitative • Assist health services to track improvement processes • Better aligned planning, reporting, governance and accreditation • Contribute over time to identifiable and achievable benchmarks

21. Standard 3 Accredited interpreters are provided to patients who require one Measure 3.1 Numerator: Number of CALD consumers/patients identified as requiring an interpreter and who receive accredited interpreter services _____________________________________ Denominator: Number of CALD consumers/patients presenting at the health service identified as requiring interpreter services Domain: Risk management Standard 3 Accredited interpreters are provided to patients who require one

22. Implementation • Planning against all six standards and key measures • Endorsed by the Board of the public health service • Lodged by 30November 2010 • One plan linked with other cultural diversity requirements • Available on health services’ website

23. Reporting • Staggered over time • Commences in 2011 Quality of carereport • 2010-2011 Standards 1, 3 & 5 • 2011-2012 Standards 2, 3, 4 & 6 • 2012-2013 All Standards

24. Health services are taking practical steps to • Review their planning, implementation and strategies against the new • standards and measures • Conduct self-assessments and a gap analysis against the measures and sub-measures • Engage key partners in the planning across health service • External stakeholders, multicultural and ethno-specific organisations and local government • Coordinate and consolidate multiple planning requirements into one planning process • Align plans within strategic planning process of health service

25. Examples form Victorian health services • Northern Health-5 campuses, mix of services including: medical, surgical, emergency, intensive and coronary care, paediatrics, women's and maternal health, mental health, aged care, palliative care, and rehabilitation programs. Provided through acute and sub-acute, inpatient, ambulatory and community-based programs. • Transcultural & Language Services Department - responsible for developing the Cultural Responsiveness Plan • High concentration of socio-economic disadvantage, and associated poor health • More than 126 different countries of birth and more than 118 languages spoken by the population and large numbers of specific language groups • Higher proportion (29.3%)of Aboriginal and Torres Strait Islander people compared to other areas in Melbourne

26. Implemented Strategies Maximised use of in-house interpreters Internal translation of medical materials – translations data base Transcultural training sessions (70+ sessions in 2010) Translations Waiting List & Database Research on Length of Stay of non-English speaking patients Video interpreting Language Student Placements Targeted Community Consultations Partnerships with ‘ethno-specific’ organisations http://www.nh.org.au/about-northern-health/w1/i1001184/ Northern Health

27. Eastern Health • Comprised of 7 hospitals sites in the eastern region of Melbourne Victoria. • Delivering acute, sub-acute, palliative care, mental health, drug and alcohol, residential care and community health services • Since 1996, Transcultural Services Unit has trialled new initiatives and developed internationally utilised communications • Cue Cardsin community languages • Development of transcultural health policies and procedures • Cultural awareness training for staff and interpreter training • Researched development of training materials and new resources • 3 industry awardsand the receipt of an outstanding achievement in most recent accreditation for provision for consumers/patients from culturally and linguistically diverse backgrounds • http://www.easternhealth.org.au/services/interpreting.aspx'

28. Access and equity for all groups Improved consumer ‘health literacy’ and reduced delays in seeking health care and treatment Improved communication and understanding of meanings between health consumers and providers resulting in: better adherence with recommended treatment clearer expectations reduced medical errors and adverse events improved attendance at follow-up appointments improved consumer satisfaction reduced hospitalisation rates Reduced failure to attend and readmission rates Consumer/patient satisfaction with health care Patient safety and quality assurance Public image of health service Business practice and better use of resources (Stewart, 2006). Benefits of culturally responsive care

29. Opportunities and challenges • Achievements are a foundation to build upon • Informed by gap analysis and self assessment • Some standards are aspirational - measures and sub-measures are used to guide achievement • Data: some not currently collected or recorded and health services have different data collection systems in place • Coordination with other cultural diversity policy and reporting requirements across health service • Implementing a whole-of-organisation training approach

30. Lessons Learned • Health service participation - critical • Consultation and discussion with health services across the state • Testing the draft framework and standards with health services • Drawing from an international research and evidence base • Setting standards to work towards over time • Linking standards to existing reporting requirements • A progression of building upon successful practices towards culturally responsive healthcare and integrated with key policy and legislative frameworks

31. In the pipeline • Development of an assessment framework for the cultural responsiveness plans • Development of appropriate feedback processes to health services • Monitoring of standards and development of benchmarks over time • Conducting a Cochrane Systematic Review investigating • Cultural competence education for health professionals to improve health outcomes in acute settings • Development of an education and training module for Victorian health services

32. Links • www.health.vic.gov.au/cald/cultural-responsiveness-framework • Framework and research report documents www. health.vic.gov.au/patientcharter • Australian Charter of Healthcare Rights in Victoria www.health.vic.gov.au/clinrisk/publications/clinical_gov_policy.htm • Victorian clinical governance policy framework www.health.vic.gov.au/consumer/participate.htm • Consumer, carer and community participation and information, and the Doing it with us- Strategic Direction 2010-13 www.health.vic.gov.au/hospitals/ • Department of Health - Victoria’s Hospital System